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Cytology

The Cytology Laboratory prepares cellular samples for light microscopy, and evaluates those samples, primarily for the identification of pre-malignant and malignant cell changes. Specimen types are body fluids, fine needle aspiration of tissue, and pap smears.

Hours and Contact Information
Monday - Friday 8:00 am - 5:00 pm
Cytology: (585) 922-4431

The department Supervisor or a Cytotechnologist is available Mon - Fri, 8am - 5pm. At all other times, please call the pathologist "on call" through the page operator.

Chief, Department of Pathology & Laboratory Medicine: Dawn K. Riedy, MD  (585) 922-4962
Director of Cytology: Karen Clary, MD (585) 922-3632
Senior Manager: Joe Foti, BS SCT (ASCP), (585) 922-9878
Supervisor: Elizabeth Parker, CT(ASCP), (585) 922-9879
Specimen Guidelines

Specimens are submitted to Cytopathology for the interpretation of pathologic conditions, primarily cancer. Cytologic examination may also reveal information about inflammatory conditions, fungi, bacteria and some viruses. Specimens submitted are fresh body fluids, brushing, swab, scraping, or aspirations. Additionally, specimens may be submitted as microscopic slide specimens, such as pap smears and aspiration biopsy specimens.

Specimen Identification

It is the responsibility of the clinician to ensure specimens are properly identified as to patient and specimen type. The body fluid container (not the container lid) must have patient identification on it. Glass slides submitted must have the patient last name in pencil, on the frosted edge of the slide.

Preservation of Specimen

Specimens are collected without preservatives or other additives. Refrigerate specimens if transportation is delayed more than an hour. All glass slides should be placed in Pap Smear Fixative (95% ETOH)

Transportation of Specimen

Outpatient specimens - Rochester General Hospital (585) 922-1096, provides free specimen pickup, on pre-arranged schedules. Special transportation may be arranged as well.

Inpatient specimens - Are delivered directly to the laboratory.

Body fluid/fresh specimens must be transported in a sealed biohazard bag, with the patient requisition placed in the pocket flap.

Requisitions

The clinician must ensure the requisition is complete, including:
1.     Patient name
2.     Date of birth
3.     Demographics
4.     Attending/ordering physician
5.     Date specimen was obtained
6.     Pertinent billing information
7.     Pertinent clinical history
8.     Specify anatomic site of specimen
Note: Multiple sites of the same procedure (e.g.: aspiration biopsy at 2:00 pm and 4:00 am) must be specified as such to provide for site specific reporting.
9.     Specify collection method (brush, broom, catheter, aspiration, discharge, induced sputum,etc).
10.   Clinical findings on examination (mass, adenopathy, friable cervix, x-ray/CAT findings, CHF, infections, etc.)
11.   Previous clinical history (malignancy, cirrhosis, effusions, radiation / chemotherapy)
Additional Requisition Information Required for GYN Pap Smears
1.     Date of the first day of menses, for the last known menstrual period (LMP).
2.     Exogenous hormone use
3.     Clinical history of induced menses (even though patient may be P.M., if being cycled with ERT, please give dates).
Clinical findings on pelvic exam (mass, erosion, post menopausal bleeding, friable cervix)

Special Stains For Cytopathology Specimens:

Are ordered by Laboratory personnel only. Providing the appropriate clinical information will ensure the proper tests are ordered in a timely manner.

Report Terminology:

The cytopathology division uses descriptive terminology in reporting pathologic conditions. The Bethesda system is incorporated into the descriptive nomenclature.

Result Reporting:

All patient reports are delivered to the patient's physician or clinic, upon completion of the testing. FAX/phone reporting is utilized on "Rush / STAT" specimens. Results of tests are not given to patients.

Follow-Up Letters:

As per NYS-DOH regulations, we will send letters requesting follow-up information on all GYN cases of Squamous Intraepithelial Lesions and more serious cases when follow-up is not apparent in the laboratory.

Requisition And Supplies:

Contact the Cytology Office at (585) 922-4431 or give a completed form to the courier for:

GYN requisitions Pap smear fixative
Non-GYN requisitions Cervical scrapers
Microscopic slides Specimen sample containers
Cervical sampling brooms & brushes
(Note: cytology supplies are NOT sterile)

Priorities And Turnaround Times:

ASAP: These specimens are given a priority over routine reporting, provided they do not interfere with STAT reporting.

RUSH/STAT: Emergency. It is imperative to have immediate reporting for patient care. Specimens receive priority status, and will be given same day service, for preliminary reporting. A preliminary report can be provided to the clinician within an hour of receipt if requested.

Routine Pap Smear: Turn around time, ideally is three days from receipt of the slides.

Routine Body Fluids: Are reported routinely within 1-2 days.

Transportation Of Specimens:
  • Syringe needles must NEVER be transported
  • Transportation of a body fluid Cytology specimen must be in a closed transport bag.
  • The Cytology requisition must be transported in such a way as to prevent contamination with body fluids, and protect patient privacy.
  • Specimens will be brought to the Cytology Lab. If special circumstances exist, arrangements can be made by phoning the Cytology Division (585) 922-4431.

Receipt of a routine body fluid specimens during working hours:

  • By Cytology personnel at the specimen preparation room, located in the Cytology Division,  Department of Pathology.
  • A routine specimen is "received" on the day of delivery, if received prior to 3 pm, Mon - Fri, OR if   prior arrangements have been made with Cytology personnel.

Receipt of a routine body fluid specimens after working hours:

  • Specimens delivered are placed in the laboratory refrigerator located outside Hematology in the  main hospital lab.
  • Specimens delayed for delivery to the Cytology division should be refrigerated until delivery, but not allowed to freeze.

Adequacy Of The Specimen:

**If abnormal cells are detected, the specimen is never categorized as "unsatisfactory" for interpretation. The specimen may be considered "satisfactory but limited by..." based on the criteria defined below.

Four elements comprise the adequacy of the specimen for the detection of abnormalities:

  1. Patient And Specimen Identification: Correct specimen identification is essential for accurate evaluation. Further, proper identification of the patient enhances the ability of the laboratory to locate prior records and slides from the patient that may influence the current evaluation.
  2. Pertinent Clinical Information: The provision of pertinent clinical information should increase the  sensitivity and reliability of the evaluation. These data may clarify otherwise uncertain cytologic  findings, and laboratories often use this information to select cases for special review. A specimen lacking pertinent clinical information may not receive the extent of review or clinical correlation it  would have received had that information been provided.
  3. Technical Interpretability: The cellular constituents must be interpretable for diagnostic evaluation. A variety of factors may impair or prevent such an interpretation.
    • The apparent condition of the specimen indicates that it is unsatisfactory for testing or that it is nappropriate for the test required.
    • It has been collected, preserved or otherwise handled in such a manner that it has become  unsatisfactory or unreliable as a test specimen.
    •  The slide(s) are broken to such extent that they cannot be repaired adequately so that cells are  not  obscured or lost.
  4. Cellular Composition And Sampling: Cellular elements form the microscopic basis for  interpretation  of pathologic conditions. The microscopic evaluation of cellular elements, clinical history, sampling technique and anatomic site establish the parameters for interpretation. Pap Smear specific cellular composition: Sampling of the Transformation zone: The specimen  must contain both squamous and endocervical or metaplastic cells. These cellular elements  form  the microscopic basis for the assumption that the transformation zone has been sampled. Endocervical component as a measure of specimen adequacy is still inconclusive, and further, the presence of squamous and glandular cells does not guarantee adequate sampling of the transformation zone. (i.e.: an optimal specimen from a post menopausal patient may lack endocervical cells.The clinician ultimately determines what is "adequate sampling" for an individual patient, based on integrating information from the clinical history, visual inspection of the cervix, and the cytopathology report.

Slide Specimens (PAP smears, brush, aspirate samples)

Purpose: To preserve cellular morphology through proper handling and fixation of the specimen.

Procedure:

  1. Slides must be immediately fixed in 95% Ethyl alcohol (pap fixative)
  2. Specimen samples are adhered to ONE side only, of the microscopic slide.
  3. Thick samples are not optimal for microscopic evaluation.
  4. Slides must be labeled with the patient last name, in pencil. (It is recommended that the labeling be done prior to distributing the specimen on the slide, to avoid specimen drying).
Pap Smears

Patient Preparation:
  • Patients should be advised NOT to douche, use vaginal medications, or have intercourse 24 hours prior to the pap smear preparation.
  • Patients should NOT schedule pap smear exams during menses. These situations may obscure cellular details or remove diagnostic material from the cervix or vagina.
Sample Collection:

Preferred collection technique:
  1. Cervical broom: After the speculum is in place, the soft brush end of the broom is inserted to allow the longer center bristles to enter the endocervical canal. The shorter soft side bristles should brush the cervix. The broom in place, should be rotated 360 degrees in one direction for 3 - 5 full rotations. This technique allows for optimal endo and ectocervical sampling, using a single slide preparation. The sample is wiped across the surface of the microscope slide. If liquid-based cytology is used, the head of the broom is detached and dropped into the preservative vial. The vial must be labeled with the patient’s name.
     

Alternative collection technique:

  1. Cervical brush: This device should be used in conjunction with the cervical scraper. The soft bristle end is inserted gently into the endocervical canal, and rotated. The sample is wiped (while rotating the bristles) across the surface of the microscopic slide.
     
  2. Cervical Scraper: the wooden spatula is used in conjunction with the cervical brush. The concave end of the wooden spatula is scrapped against the ectocervix, and the sample is immediately wiped onto a microscopic slide.
Aspiration Biopsy

Patient Preparation:
  • Lesions are identified through imaging techniques or palpation.
  • Skin is prepared with alcohol sponge as for venipuncture.
  • Lidocaine local from skin to lesion edge may be used to allow for good needle placement.
Sample Collection:
 
  • For aspirations of the Thyroid, NO NEGATIVE PRESSURE is applied. The needle is simply inserted into multiple locations of the nodule. This process reduces the dilution of the specimen with blood.
  • All the steps are to be done as quickly as possible to ensure an optimal result.
  • Cytology staff is available during work hours for assistance in in-house specimen collection during  the aspiration procedure. Advance notice to the staff is requested.
Preferred specimen collection:

Caution: Protective clothing and equipment, including mask, gown and gloves, must be worn throughout this and every preparatory procedure.
 
  • One method is to use a 22- 25 gauge needle without a syringe. The finer the needle, the less  trauma  caused.
  • The needle is DISCONNECTED from the syringe (if used) and the syringe is filled with air by retracting the plunger.
  • The needle is reconnected to the syringe and the material is expelled from the needle onto the glass slides.
  • If the material on the slide appears both bulky and excessively bloody, two smears are made by placing another clean glass slide on top of the specimen coated one (permitting the weight of the upper slide to spread the material), pulling the slides apart to obtain a thin coat before alcohol immersion.
  • To ensure rapid fixation without drying artifact, immediately and gently, immerse the slides in 95% ethyl alcohol.
  • It is highly recommended to thoroughly flush the needle and syringe with 20-30 milliliters of electrolyte-buffered solution and eject the contents into a small container/centrifuge tube for  additional processing.
  • Any visible chunks of tissue should be removed from the specimen and prepared as tissue, placing them in buffered formalin.
  • It is highly recommended that the specimen container be labeled with the patient name.
Alternative collection method: IMMEDIATELY after aspiration of body tissue:
 
  • Eject all material into a small clean container/centrifuge tube with 20-30 milliliters of electrolyte-
  • buffered solution.
  • It is thoroughly recommended to flush the needle and syringe with electrolyte-buffered solution as well, and eject this into the same container as the specimen.
  • Cap/lid specimen securely, for immediate transportation.
  • It is highly recommended to label the container with the patient name.
  • Any chunks of tissue should be removed and placed in buffered formalin to be processed as a tissue.
  • If the aspiration is repeated on the same patient, the glass slides should be labeled to reflect another attempt, or another sampling location at the time of the procedure. This is done using a lead pencil inscription on the frosted end of the slide.

NOTE:

Thyroid:
The patient should be placed in the supine position with the neck hyperextended.
Breast:
Once the mass is punctured, FULL suction is applied to the aspirating syringe, and the needle is moved back and forth.
Salivary Glands:
Aspiration can be very difficult due to blood or lymph dilution in suspected hemangioendotheliomas and lymphangiomas (cystic hygromas). The non-aspiration technique is often helpful in conjunction with multiple samples. Remove needles quickly to avoid needle track blood, and use digital pressure at biopsy site to avoid hematoma formation.
Lung:
Some investigators consider advanced Emphysema, uncontrollable cough, and pulmonary  hypertension as contraindications to the FNA procedure in the lung.Simple pneumothorax may occur in up to 35% of patients, and is of no clinical significance.  Pneumothorax to some extent can be avoided if the needle is not handled while the patient is  breathing.
Transbronchial:
As a special modification for those cases where the lung lesion has not invaded through the mucosa into the bronchial lumen, and thus is not accessible through sputum or bronchial brushing. This procedure involves the insertion of a flexible needle through the fiberoptic bronchoscope, penetration of the bronchial wall and aspiration of cytologic material lying beyond.
Bone:
FNA will generally be successful only with destructive lesions, preferably those associated with destruction of cortical bone.
Pancreas:
Although major vessels should be avoided, no special precautions are needed to avoid passage of the needle through the liver or bowel. Aspiration may be carried out by direct insertion of the needle into the lesion.

Body Fluid Specimens
Washes, of body cavities:
NOTE:
  • Bladder Wash: recommended for symptomatic patients, and can be done as a part of cystoscopy procedure.
  • Ureteral washings should be labeled right or left.
Patient Preparation:

Esophageal or gastric wash: vegetable cells may heavily contaminate washing specimens, particularly if there is an impediment to gastric emptying. In this circumstance, the patient may be placed on a liquid diet, and the procedure repeated.

Sample Collection:
  1. Specimens may be obtained by instilling physiologic saline solution into the various recesses of the peritoneal cavity or any site to be sampled, then withdrawing the fluid and submitting it for cytologic examination as a "washing".
  2. Peritoneal dialysate from patients undergoing peritoneal dialysis for renal failure is occasionally submitted for cytologic examination.
  3. Bronchial washes and lavages are obtained through infusion and reaspiration of sterile saline through a fiberoptic bronchoscope.
  4. Bronchio-alveolar lavage may be useful in the identification of Pneumocystis carinii organisms.
  5. Esophageal or gastric wash: Note oily lubricants may obscure cellular details, and therefore are  NOT recommended.
  6. Esophageal or gastric wash: washes should always precede a barium swallow, if a barium swallow is scheduled.
Spontaneous Effusions

Patient Preparation: no special instructions.

Sample Collection:

 
  1. Although a serous effusion may be removed at the time of surgical exploration, it is usually removed by the relatively simple procedure of inserting a wide bore needle through the body wall into the cavity containing the fluid.
  2. Small amounts, only a few cc's of fluid can be prepared.
  3. Specimens are collected without alcohol or other fixatives added
  4. CAUTION: Formalin, alcohol or any other kind of cellular preservative MUST NOT be added to specimens of serous fluid sent to our laboratory. Not only does formalin prevent cells from adhering well to a slide, but it also interferes with the quality of staining by the Papanicolaou method. Adding alcohol causes some precipitation of protein in virtually all specimens, thereby interfering with adherence of the cells to the slide. Additionally, the use of formalin or alcohol, is not necessary because keeping the specimen at refrigerator temperature, even for several days, will preserve cells well.
  5. Anticoagulation is not required.
  6. The fluid is collected into a clean, dry container, (which need not be sterile), and sent to the  laboratory as soon as possible. Specimen container should have a secure lid/cap.
    NOTE: If the specimen is being used for microbiological studies, a sterile container may be   required. The specimen MUST be delivered to microbiology prior to cytology. Contact Microbiology for instructions.
  7. If it is not possible to transport the fluid immediately, it should be stored in a refrigerator, and not allowed to freeze.

    Urine:
NOTE:
  1.  It is of major importance that a catheterized specimen be labeled as such, as cellular findings are altered through instrumentation.
  2. Voided urine is the specimen of choice for all screening programs and for diagnostic studies in males because of the ease of collection and satisfactory results.
  3. For suspected lesions of the renal pelvis or the ureter, examination of the voided urine is often satisfactory.
  4. 24 hour collections are unsatisfactory for cytologic evaluation, due to cellular degeneration.
  5. Catheterization of the upper ureteral tract is necessary to sample specific anatomic sites. 
  6. Catheterized specimens are preferred specimens from female patients.
  7. Urine specimens obtained through instrumentation do not contain cellular contamination from other anatomic sites.

    Patient Preparation: No special instructions.

Sample Collection:

Voided urines:

  • A first morning voided, midstream collection is best.
  • Collect into a clean specimen container.
  • No fixatives/preservatives are added. An equal amount of 50% ethyl alcohol may be added to the specimen for preservation of the cellular material, if specimen delivery is anticipated to be delayed for  a couple days.

    Catheterized urine:
  • The catheter itself is a semi-flexible tubing apparatus introduced into the bladder or ureter for the withdrawal of urine.
  • All specimens are collected into a clean specimen container.
  • An equal amount of 50% ethyl alcohol may be added to the specimen for preservation of the cellular material, if specimen delivery is anticipated to be delayed for a couple days.

Sputum
 

NOTES:

  • Patients should be instructed that thin, watery specimens are unsatisfactory for evaluation, and that early morning deep coughs are most productive
  • It is recommended to submit 3 consecutive early morning deep cough specimens.
  • 24 HR. sputum is NOT an acceptable specimen.
  • No solutions are to be added to the specimen.
  • If microbiology studies are to be performed on the SAME specimen, it must first be sent to the  microbiology department. Note: a sterile container may be recommended for microbiology studies. Contact the Microbiology laboratory for instructions.
  • If the sputum specimen is delayed in delivery to the cytology division, it must be refrigerated.
  • Induced sputum are appropriate in patients who cannot produce sputum spontaneously. The basic principle involves the inhalation of some appropriate solution the has been aerosolized. The  inspired  vapor stimulates mucous production.
  • Sputum specimens are not the appropriate specimen for Pneumocystis evaluation.

Patient Preparation:
Patients should be instructed that for spontaneous sputum production: thin, watery specimens are unsatisfactory for evaluation

Sample Collection:

  • Deep cough sample, spontaneous sputum production: collect into clean container. No fixative or preservatives are added.
  • Post-bronch sputum, spontaneous sputum collection: collect into a clean container. No fixative or preservatives are added.
  • Induced sputum: collection into a clean container. No fixative or preservatives are added.

Brushings
 

NOTES:

It is preferable to obtain the brush sample before the biopsy because the latter results in bleeding, which both obscures the lesion, and detracts from the quality of a subsequently collected cytologic sample, whereas interpretation of the biopsy is not affected by the reverse order of collection.Collection of a good brush sample usually requires an experienced assistant, because the operator may well be engaged in maneuvering the end of the scope and holding the lesion in focus while the assistant manipulates the brush. Therefore, it is ideal that a Cytology staff member be present for immediate slide preparation of the specimen.

Patient Preparation: No special instructions.
 

Sample Collection:

  • The cytologist labels the slides, and readies the fixative (95% ethyl alcohol) bottles prior to obtaining the brush from the endoscopist.
  • After abrasion, the endoscopist pulls the brush back, just within the teflon sheath, and the entire sheath is withdrawn, and handed to the cytotechnologist (or cytology assistant).
  • If multiple brushing are performed, it may be important to note the approximate location of each 
    sample, by notation with a lead pencil onto the frosted end of the slide.
  • If lymphoma is suspected, air dried slides are useful.

* As many slides as possible are made from the brush sample with immediate fixation to avoid air drying.

CAUTION: THE MANIPULATION OF THE BRUSH ONTO A GLASS SLIDE DISPERSES SPECIMEN DROPLETS INTO THE SURROUNDING AIR.

*The slides should be separated by placing paper clips on the frosted end, if placed in containers without spacers.

Cerebrospinal Fluids

NOTES:

  • The diagnostic accuracy improves with the collection of larger samples. If several samples are obtained, the second or third should be used for cytology.
  • Specimens are collected without alcohol or other fixatives added.
  • When a fungal infection is clinically suspected, the requisition should note this to be sure the appropriate histochemical stains are performed.

Patient Preparation: No special instructions.

Sample Collection:

CAUTION: Formalin, alcohol or any other kind of cellular preservative MUST NOT be added to specimens of cerebrospinal fluid sent to our laboratory. Not only does formalin prevent cells from adhering well to a slide, but it also interferes with the quality of staining by the Papanicolaou method. Adding alcohol causes some precipitation of protein in virtually all specimens, thereby interfering with adherence of the cells to the slide.
 

  • Usually a small amount of fluid is collected through a lumbar tap. However, fluid may be aspirated  from the ventricular and suboccipital space as well. The ventricular fluid is frequently the most cellular specimen.
  • The fluid is collected into a clean, dry container, (which need not be sterile), and sent to the laboratory  as soon as possible. Specimen container should have a secure lid/cap.